Transosseous guide

ABSTRACT

Instruments and methods for surgical transosseous attachment to a bone include a guide able to guide the formation of intersecting bone tunnels and a passer able to pass a member through the bone tunnels.

FIELD OF THE INVENTION

The invention relates to transosseous guides and methods fortransosseous attachments.

BACKGROUND

A variety of surgical procedures require the attachment of somethingrelative to a surgical site. For example, in surgery relating to theskeletal system, it is often advantageous to attach soft tissue, suture,implants, and/or other items in or adjacent to a joint. For example,soft tissues such as ligaments, tendons, fascia, other capsularmaterial, and/or muscle may be attached to an adjacent bone. Such softtissues may be adjacent to bones at skeletal joints including but notlimited to the joints of the hands and feet, ankle, wrist, knee, elbow,hip, shoulder, and spine. For example, it is often advantageous to passa suture through a portion of a bone to form a transosseous attachmentto the bone.

SUMMARY

Examples of the invention provide instruments and methods for surgicaltransosseous attachment to a bone.

In one example of the invention, a method for placing a membertransosseously through first and second transverse, intersecting bonetunnels includes inserting a first tunnel member into a bone along afirst insertion axis, the first tunnel member having a proximal end anda distal end, the first tunnel member having a first longitudinalpassage at least partway through the first tunnel member; inserting asecond tunnel member into the bone along a second insertion axis, thesecond insertion axis intersecting the first insertion axis, the secondtunnel member having a proximal end and a distal end, the second tunnelmember having a second longitudinal passage at least partway through thesecond tunnel member; inserting a passer through the first and secondtunnel members, the passer simultaneously extending through the firstand second axial passages and out of the proximal end of the firsttunnel member and out of the proximal end of the second tunnel member.

In another example of the invention a method for placing suturetransosseously through first, second, and third transverse, intersectingbone tunnels includes forming a first bone tunnel in a bone with a firsttunnel member; forming a second bone tunnel transverse to andintersecting the first bone tunnel with a second tunnel member; placinga first portion of suture through the first and second bone tunnels andat least partway through the first tunnel member; forming a third bonetunnel transverse to and intersecting the first bone tunnel with thesecond tunnel member while the first flexible element is present in thefirst tunnel member; placing a second portion of suture through thefirst and third tunnels and at least partway through the first tunnelmember while the first flexible element is present in the first tunnelmember.

In another example of the invention, a method for placing a membertransosseously through first and second transverse, intersecting bonetunnels includes inserting a first tunnel member into a bone along afirst insertion axis, the first tunnel member having a proximal end anda distal end, the first tunnel member having a first longitudinalpassage at least partway through the first tunnel member; using a guideto select a second insertion axis from a plurality of insertion axesthat each intersect the first insertion axis, each of the plurality ofinsertion axes forming a different angle relative to the first insertionaxis; inserting a second tunnel member into the bone along the selectedsecond insertion axis, the second tunnel member having a proximal endand a distal end, the second tunnel member having a second longitudinalpassage at least partway through the second tunnel member; inserting apasser through the first and second tunnel members, the passersimultaneously extending through the first and second axial passages andout of the proximal end of the first tunnel member and out of theproximal end of the second tunnel member.

BRIEF DESCRIPTION OF THE DRAWINGS

Various examples of the present invention will be discussed withreference to the appended drawings. These drawings depict onlyillustrative examples of the invention and are not to be consideredlimiting of its scope.

FIG. 1 is a side elevation view of an example of the inventionillustrating an instrument engaged with a bone, the bone being shown inpartial section;

FIG. 2 is a side elevation view of an example of a passer used with theinstrument of FIG. 1;

FIG. 3 is a detail side elevation view of the tip of the passer of FIG.2;

FIG. 4 is a detail front elevation view of the tip of the passer of FIG.2;

FIG. 5 is a side elevation view of the instrument of FIG. 1 engaged witha bone and the passer of FIG. 2 inserted through the instrument;

FIG. 6 section view taken along line 6-6 of FIG. 1;

FIG. 7 is detail side section view of the instrument of FIG. 1 showingthe passer engaged with the instrument in a first position;

FIG. 8 is detail side section view of the instrument of FIG. 1 showingthe passer engaged with the instrument in a second position;

FIG. 9 is a side elevation view of an example of the inventionillustrating an alternative arrangement of the instrument of FIG. 1;

FIG. 10 is a top plan view of the instrument of FIG. 9;

FIG. 11 is a section view taken along line 11-11 of FIG. 10;

FIG. 12 is a side elevation view of an example of the inventionillustrating an alternative arrangement of the passer of FIG. 2 in afirst position;

FIG. 13 is a side elevation view of the example of FIG. 12 in a secondposition;

FIG. 14 is a partial sectional view of the bone of FIG. 1 after a suturehas been passed and the passing instruments have been removed;

FIG. 15 is a partial sectional view illustrating the suture of FIG. 14in use to secure a soft tissue to the bone;

FIG. 16 is a rear elevation view of the guide of FIG. 1 illustrating howit can be rotated while engaged with a bone;

FIG. 17 is a perspective view of the guide of FIG. 1 illustrating how itcan be rotated while engaged with a bone; and

FIGS. 18-28 are perspective views of methods according to examples ofthe invention.

DESCRIPTION OF THE ILLUSTRATIVE EXAMPLES

The following illustrative examples depict instruments and methods toform a tunnel through a bone and pass a member through the bone tunnel.The illustrative examples depict passing a round suture through a bonetunnel to attach soft tissue to the bone. However, the instruments andmethods of the invention may be used to pass other elements through abone tunnel including, suture passers, suture tapes, cables, softtissues, grafts, and other elements. Examples of instruments and methodsof the invention may be used to pass any member through any bone, atsurgical sites anywhere in a patient's body, and for any purpose. Theterms “suture” and “suture strand” are used herein to mean any strand orflexible member, natural or synthetic, able to be passed through a bonetunnel and useful in a surgical procedure. The term “transverse” is usedherein to mean to cross at an angle; i.e. not parallel. The termincludes, but is not limited to right angles.

FIGS. 1-8 depict examples of a guide and a passer for formingintersecting bone tunnels in a bone 198 and passing a flexible elementthrough the tunnels. The exemplary guide 100 includes a guide body 102defining a first insertion or guide axis 104 and a second insertion orguide axis 106 intersecting at a location 108 spaced from the guidebody.

A first tunnel member 110 is engageable with the guide body 102 coaxialwith the first guide axis 104 and includes a proximal end 112, a distalend 114, and a first longitudinal passage 116 (FIG. 7) at least partwaythrough the first tunnel member 110.

A second tunnel member 120 is engageable with the guide body 102 coaxialwith the second guide axis 106 and includes a proximal end 122, a distalend 124, and a second longitudinal passage 126 (FIG. 7) at least partwaythrough the second tunnel member 120.

A passer 136 (FIG. 2) is operable to extend from the proximal end 122 ofthe second tunnel member 120, through the distal end 124 of the secondtunnel member 120, through the distal end 114 of the first tunnel member110, and to the proximal end 112 of the first tunnel member 110 in onecontinuous path. The passer 136 may then be used to pull a flexibleelement such as, for example, a passing suture or a repair suturethrough the tunnel members 110, 120 to pass the flexible elementthrough, for example, a bone.

In the illustrative embodiment of FIGS. 1-8, the guide body 102 is madeup of first and second arc members 130, 132. The first and second arcmembers 130, 132 are joined in sliding relationship along an arc shapedpath 134 of constant radius such that the guide 100 is adjustablebetween a first position (shown in solid lines in FIG. 1) in which thefirst guide axis and the second guide axis define a first angle betweenthem and a second position (shown in dashed lines in FIG. 1) in whichthe first guide axis and the second guide axis define a second, largerangle between them. Preferably, the guide is continuously adjustableover a range of included angles between the first and second guide axes104, 106 of from 20 to 110 degrees. More preferably, the range is 60 to90 degrees. In the illustrative example of FIGS. 1-8, the first guideaxis 104 is defined by a passage in the first arc member 130 and thesecond guide axis 106 is defined by a passage in the second arc member132.

The first tunnel member may include a drill guide, a punch guide, apunch, or other suitable member for forming a bone tunnel and/or forinserting into a bone tunnel. In the illustrative example of FIGS. 1-8,the first tunnel member 110 is a bone punch fixed to the guide body suchas by pinning, threading, welding, or other suitable fixation method.For example, the first tunnel member 110 may be impacted into the bone198 to form a bone tunnel in the bone. In the illustrative example ofFIGS. 1-8, the first tunnel member 110 includes a cylindrical bodyhaving a first, larger diameter 140 near its proximal end 112 and asecond, smaller diameter 142 near its distal end with a taperedtransition region 144 between the two diameters. The cylindrical bodydefines a first outer side wall and a first recess or side opening 146(FIG. 7) in the first side wall nearer the distal end 114 than theproximal end 112. The second guide axis 106 passes through the firstside opening 146 for every angle in the range of adjustment of the firstand second arc members 130, 132. The first longitudinal passage 116extends from the proximal end 112 of the first tunnel member 110 towardthe distal end 114 and communicates with the first side opening 146. Arelief opening 148 in the side wall is positioned opposite the firstside opening 146 and communicates with the first longitudinal passage116 and the first side opening 146. The first tunnel member 110 includesindicia 150 (FIG. 1) on the outer surface readable relative to the bonesurface to indicate a depth of penetration of the first tunnel member110 into the bone. In the illustrative example of FIGS. 1-8, the indicia150 include two separate marks to indicate the appropriate depth for twodifferent sizes of anchor. In the illustrative example of FIGS. 1-8, thefirst tunnel member 110 tapers to a solid, sharp point 152 distal to thefirst side opening 146 and the relief opening to facilitate driving thefirst tunnel member 110 into bone.

The second tunnel member may include a drill guide, a punch guide, apunch, or other suitable member for forming a bone tunnel and/orinserting into a bone tunnel. In the illustrative example of FIGS. 1-8,the second tunnel member 120 is a punch engageable with the guide 100 inaxial sliding relationship along the second guide axis 106. For example,the second tunnel member 120 may be impacted into the bone 198 to form abone tunnel in the bone. In the illustrative example of FIGS. 1-8, thesecond tunnel member 120 includes a body having a “D”-shaped proximalportion 160 and a smaller cylindrical distal portion 162 with a taperedtransition region 164 between the two portions. The body defines asecond outer side wall and a second side opening 166 (FIG. 7) in thefirst side wall nearer the distal end 124 than the proximal end 122. Inthe illustrative example of FIGS. 1-8, the second longitudinal passage126 extends from the proximal end 122 of the second tunnel member 120toward the distal end 124 of the second tunnel member 120 andcommunicates with the second side opening 166. The second tunnel member120 tapers to a solid, sharp point 168 distal to the second side opening166 to facilitate driving the second tunnel member 120 into bone. Thesecond tunnel member 120 includes an indicator to indicate when it isengaged with the first tunnel member 110. In one example, the secondtunnel member 120 includes an index mark 170 on the outer surfacereadable relative to the guide 100 to indicate a depth of penetration ofthe second tunnel member 120 into the bone. In the illustrative exampleof FIGS. 1-8, the distal portion 162 of the second tunnel member 120 isengageable within the first side opening 146 of the first tunnel memberwith the first side opening 146 and second side opening 166 incommunication with one another. The index mark 170 on the second tunnelmember 120 indicates when the distal end of the second tunnel member 120is seated in the first side opening 146. In another example, the secondtunnel member 120 has an elongated marker such as for example acontrasting surface 171 that is exposed to indicate when the secondtunnel member is not properly seated. The surface 171 extendsproximally-distally the distance of the engagement of the second tunnelmember 120 with the guide body 102. When the second tunnel member 120 isproperly seated, the surface 171 is covered by the guide body 102. Ifthe second tunnel member 120 is not fully seated, the surface 171 isvisible above the guide body. If the second tunnel member is inserted tofar, for example if is deflects upon insertion such that it misses thefirst tunnel member and is driven past the first tunnel member, thesurface 171 is visible below the guide body. In one example, the surface171 includes a colored stripe, for example a red colored stripe, suchthat if red is visible after inserting the second tunnel member itindicates that the second tunnel member is not properly seated. Forexample, in FIGS. 1 and 21 the surface 171 is visible above the guidebody 102 and in FIGS. 5 and 22 the surface 171 is concealed by the guidebody 100.

The relief opening 148 in the first tunnel member allows bone chips orother debris to exit the first tunnel member 110 when the second tunnelmember 120 engages it. In the illustrative example of FIGS. 1-8, anangled surface 172 is formed at the distal end of the secondlongitudinal passage 126 facing the second side opening 166. The angledsurface 172 deflects the passer 136 through the second side opening 166and into the first longitudinal passage 116 when the passer is inserted.The “D”-shape of the proximal portion 160 of the second tunnel member120 engages the guide 100 to prevent rotation of the second tunnelmember 120 as it axially translates so that the first and second sideopenings 146, 166 are aligned when the first and second tunnel members110, 120 are engaged.

The length of the first and second tunnel members 110, 120 that extendsfrom the guide body to their intersection location may be any desiredlength. However, it has been found by the inventors that for rotatorcuff repair surgery on a human shoulder, a length of each member in therange of 2-8 inches is useful. More preferably the length is in therange of 4-6 inches. The length for each member may be the same ordifferent. In the example of FIGS. 1-8, the length of the first tunnelmember extending from the guide body is approximately 5.5 inches and thelength of the second tunnel member extending from the guide body isapproximately 4.5 inches.

The passer 136 includes a first, or proximal, end 180 and a second, ordistal, end 182 defining a loop 188. In the illustrative example ofFIGS. 1-8, the passer 136 includes a relatively rigid shaft 184extending away from the first end and a relatively flexible wire 186attached to the shaft 184 and extending away from the shaft 186. In oneexample, the shaft 184 is a tubular member and the wire 186 is crimped,bonded, soldered, welded or otherwise attached to the shaft. In theillustrative example of FIGS. 1-8, the wire 186 is formed into a loop188 in a first plane and bent to form a curved profile 190 in a secondplane perpendicular to the first plane. The curved profile 190 of thewire and the angled surface 172 at the distal end of the secondlongitudinal passage 126 cooperate to facilitate advancing the distalend 182 of the passer from the second longitudinal passage 126 into thefirst longitudinal passage 116. The passer 136 includes a handle 192 atthe proximal end 180. Preferably, the passer, or at least the wire 186,is formed of a super elastic material. Preferably the combined length ofthe shaft 184 and wire 186 is greater than the combined length of thefirst and second longitudinal passages 116, 126 such that the passer 136is insertable through the first and second tunnel members 110, 120 toextend through the first and second axial passages and out of theproximal end 112 of the first tunnel member 110 and out of the proximalend 122 of the second tunnel member 120. For example, as the distal end182 of the passer reaches the distal end of the second longitudinalpassage 126, it abuts the angled surface 172 and is deflected outthrough the second side opening 166, through the first side opening 146and into the first longitudinal passage 116 (FIG. 7). The curved profile190 of the wire and angled surface 172 facilitate the transition of thewire 186 from the second tunnel member 120 to the first tunnel member110 and promote passage even when the first and second tunnel members110, 120 are engaged at an acute angle. The passer is further advancedto move the distal end 182 of the passer through the second longitudinalpassage and out the proximal end 112 of the first tunnel member 110(FIG. 5). A member 191, e.g. a suture, may be placed in the loop 188 atthe distal end 182 of the passer and the passer 136 may be retrieved topull the member 191 through the first longitudinal passage 116, throughthe first side opening 146, through the second side opening 166, throughthe second longitudinal passage 126 and out the proximal end of thesecond longitudinal passage 126. The passer handle includes anindicator, for example a flat surface 197, to indicate to a user theorientation of the bent loop so that the user can orient it to engagethe angled surface 172. Alternatively, or in addition, the passer may bekeyed to the second tunnel member to permit only one orientation.

FIGS. 9-11 illustrate another example of a guide instrument 300 similarto that of FIG. 1 but showing a different arrangement of the secondguide axis. The guide body 302 includes a first tunnel member 304 likethe first tunnel member in the example of FIG. 1 that defines a firstguide axis 306 as with the example of FIG. 1. However, the guide body isa unitary body having a plurality of receivers 308, 310, 312, 314, 316,318, 320 operable to receive the second tunnel member 120. Each receiverincludes a passage defining a guide axis. Any number of receivers may beincluded at any desired spacing to provide a desired selection of guideangles relative to the first guide axis. In the example of FIGS. 9-11,seven receivers are provided defining a second guide axis 328, a thirdguide axis 330, a fourth guide axis 332, a fifth guide axis 334, a sixthguide axis 336, a seventh guide axis 338, and an eighth guide axis 340.Each of the second through eighth guide axes intersects the first guideaxis 304 at the same location spaced from the guide body and each canselectively receive the second tunnel member. In the example of FIGS.9-11, each of the second through eighth guide axes intersects a sideopening 346 in the first tunnel member like the side opening 146 in theexample of FIG. 1. A surface 333 formed at the distal end of eachreceiver engages the flat side of the “D”-shaped second tunnel member120 to prevent rotation of the second tunnel member 120 within thereceiver so that the first and second side openings 146, 346 areproperly aligned when the first and second tunnel members are engaged.

In the example of FIGS. 9-11, the second through eighth guide axes areequally spaced and define angles of 45 degrees to 75 degrees relative tothe first guide axis 306. Indicia 350 on the first tunnel member 304indicates an insertion depth range suitable for a fastener, for examplea knotless fastener. Indicia 351 on each receiver indicates the anglecorresponding to each receiver. The spacing can be any desired spacingand can be uniform or non-uniform to provide a range of angles useful tothe user. The inventors have found the spacing and range shown in theexample to be suitable for typical rotator cuff procedures of the humanshoulder.

For other applications such as for example for attaching soft tissue toa bone adjacent a knee joint, ankle or other location different spacingand angular range may be desirable. Similarly, the length of the firstand second tunnel member may be varied. For example, for repairing atorn Achilles tendon, a guide having an angular range of 50 to 80degrees has been found suitable with either a sliding adjustable guidelike that of FIG. 1 or a unibody guide like that of FIG. 9. In a unibodyguide, four receivers defining axes at 50, 60, 70 and 80 degreesrelative to the first guide axis have been found to be suitable. Anylength of first and second tunnel members may be used. However, forrepairing a torn Achilles tendon, shorter lengths may advantageously beused. For example, first and second tunnel members each extending fromthe guide body a distance in the range of two to three inches has beenfound suitable.

FIGS. 12-13 illustrate another arrangement for a passer 400 similar tothat of FIG. 2. The passer 400 includes an outer tube 402 engagedcoaxially with the shaft 484 in axial sliding relationship and moveablerelative to the shaft from a first position in which the outer tubeencloses a portion of the wire length (FIG. 13) and a second position inwhich the outer tube encloses less of the wire length (FIG. 12). Theouter tube is relatively rigid relative to the wire 486. The outer tubeaids in inserting the passer 400 into the second tunnel member byholding the wire 486 in a straight and rigid configuration when the tubeis in the first position. The outer tube may enclose any portion of thewire length in the first position to aid in inserting the passer.Preferably, in the first position, the outer tube encloses more thanone-half of the wire length; more preferably 60 to 100 percent of thewire length; more preferably 80 to 100 percent of the wire length; morepreferably the entire wire length including all of the loop 488. In thesecond position, enough of the wire is exposed to allow it to extendthrough the side openings in the first and second tunnel members andthrough the first tunnel member. Preferably in the second position, theouter tube encloses less than one-half of the wire length; morepreferably less than 20 percent of the wire length. The tube may beinserted into the second tunnel member while in the first position andthen shaft 484 advanced to extend the wire 486 out of the outer tube andthrough the second and first tunnel members. For example, a handle 492on the shaft may be pressed toward a handle 493 on the outer tube toadvance the wire. The loop 488 in the example of FIGS. 12 and 13includes a first bend 487 angled away from the main portion of the wire486 and a second bend 489 at the distal end forming a small radius. Thebends 487, 489 facilitate the transition of the loop through the sideopenings of the tunnel members.

The exemplary guides and methods of the invention make it possible toform intersecting bone tunnels in a bone and extend, in one motion, apasser through the guide and bone tunnels from a first position externalto the bone to a second position external to the bone. A first end of amember, such as a suture, may then be engaged with the passer outside ofthe bone tunnels. By having the engaging step outside of the bonetunnels, it may be done with simple manual manipulation of the passerloop and the first end of the member with easy access and visibility andwithout specialized arthroscopic instrument or procedures. The first endof the member may then be passed, in one motion, through the guide andbone tunnels from the second position external to the bone to a firstposition external to the bone to thread the member through theintersecting bone tunnels. The member may be used in any desirablemanner. For example, a member in the form of a suture 194 may be sopassed and then used to secure soft tissue 196 to the bone 198 as shownin FIGS. 14 and 15.

Referring to FIGS. 16 and 17, a guide according to examples of theinvention, for example guide 100 as shown in FIGS. 16 and 17, may beused to create three or more intersecting tunnels and pass flexibleelements through the tunnels. For example, after passing a firstflexible element through first and second intersecting tunnels in a bone198, the second tunnel member 120 may be withdrawn from the bone. Theguide 100 may be rotated about the first guide axis 104, as shown atreference numeral 193, and/or the angle between the guide axes 104 maybe adjusted as shown at reference numeral 195 in FIG. 17. In a unitaryguide such as the example of FIG. 9, the angle between the guide axesmay be adjusted by inserting the second tunnel member in a differentreceiver. The second tunnel member 120 may then be inserted into thebone 198 in a new location and advanced to form a third bone tunnelintersecting the first bone tunnel. The second tunnel member 120 may beengaged with the first tunnel member 110 and the passer 136 used to passa second flexible element through the first and third tunnels. This maybe repeated as many times as desired to provide a one-to-manyrelationship between the first bone tunnel and the plurality ofadditional bone tunnels intersecting the first bone tunnel. The thirdand subsequent bone tunnels may be formed and the second and subsequentflexible elements may be passed while the first tunnel member 110remains in the bone and while the first flexible element remains in thefirst tunnel member.

FIGS. 18-27 illustrate an example of a surgical method according to theinvention. In the illustrative example of FIGS. 18-27, instruments andmethods of the previous examples are shown in use to place transosseoussutures to repair a rotator cuff 202 of a shoulder joint. It will beunderstood that any of the examples of instruments and methods of theinvention may be used in any combination to pass a member through ashoulder bone or other bones at a shoulder or other surgical sites andfor rotator cuff repair or other surgical purposes.

Referring to FIG. 18 the guide 100 is positioned with the point 152 ofthe first tunnel member 110 on the lateral surface of the greatertuberosity 200 of the humerus approximately 30 mm inferior to thesuperior border of the tuberosity. The guide 100 is oriented such thatit is perpendicular to the long axis of the humerus and perpendicular tothe acromion (not shown).

Referring to FIG. 19, the first tunnel member 110 is impacted into thebone to form a first, or lateral, bone tunnel 210.

Referring to FIG. 20, the location for a second, or medial, tunnel isvisualized using a targeting wire 204 in a targeting sleeve 206 toconstrain the wire 204 to translation along the second guide axis 106.The position of the targeting wire may be adjusted in two degrees offreedom. First, the guide 100 may be rotated about the first guide axis104 by twisting the first tunnel member 110 in the lateral bone tunnel210. Second, the guide may be repositioned by adjusting the first andsecond arc members 130, 132 to change the angle between the guide axes104, 106 (or repositioning the targeting sleeve and targeting wire in adifferent receiver in a unitary guide such as that of FIG. 9). As theseadjustments are made, the targeting wire 204 may be inserted through theskin and other soft tissues near the targeted site so that the positionmay be visualized on the bone. The small punctures in the skin and othersoft tissues created by the targeting wire 204 cause minimal trauma tothe tissues and facilitate multiple targeting attempts if needed. Thetargeting wire 204 is then used to mark the bone surface with thedesired medial tunnel location.

Referring to FIG. 21, the targeting sleeve and wire are removed and thesecond tunnel member 120 is impacted to form a second, or medial, tunnel212.

Referring to FIG. 22, the second tunnel member 120 is engaged with thefirst tunnel member 110 and the passer 400 inserted into the secondtunnel member 120.

Referring to FIG. 23, the wire is advanced through the first and secondtunnel members 110, 120 until it extends from the proximal end of thefirst tunnel member 110. The end 216 of a first shuttle suture 214 ispassed through the loop 488 of the passer 400.

Referring to FIG. 24, the end 216 of the shuttle suture 214 is retrievedby pulling the passer 136 out the distal end of the second tunnel member120.

Referring to FIG. 25, the second tunnel member 120 is removed leavingthe first shuttle suture 214 in place in the first tunnel member 110 andextending out of the second, medial bone tunnel 212.

Referring to FIGS. 26 and 27, the preceding steps are repeated to createa third, additional medial, tunnel 218 and place a second shuttle suture219 while the first tunnel member 110 remains in the bone and while thefirst shuttle suture 214 remains in the first tunnel member 110. Twolimbs 220, 222 of a first repair suture are passed through the loop ofthe first shuttle suture 214 and two limbs 224, 226 of a second repairsuture are passed through the loop of the second shuttle suture 219. Theshuttle sutures 214, 219 are pulled to pass the limbs of the repairsutures through the bone. The repair sutures are passed through therotator cuff 202 and used to secure it to the humerus 200.

Referring to FIG. 28 the instruments and methods may also be used forother repairs such as, for example, an Achilles tendon repair in whichthe first and second tunnel members are inserted into the heel bone 500and one or more sutures are passed and used to secure the Achillestendon 502 to the bone 500.

While the illustrative examples have shown bone tunnels being formed bypunching instruments into the bone, it is also within the scope of theinvention to form bone tunnels by drilling, reaming, broaching, and/orany suitable tunnel forming process. It is contemplated, and within thescope of the invention, that the various features of the illustrativeexamples may be interchanged among the illustrative examples.

The following are further examples of the invention

-   1. An instrument for placing a member transosseously through first    and second transverse, intersecting bone tunnels, the instrument    comprising:    -   a guide body defining a first guide axis and a second guide        axis, the first guide axis and the second guide axis        intersecting at a location spaced from the guide body;    -   a first tunnel member engaged with the guide body coaxial with        the first guide axis, the first tunnel member having a proximal        end and a distal end, the first tunnel member having a first        longitudinal passage at least partway through the first tunnel        member;    -   a second tunnel member engaged with the guide body coaxial with        the second guide axis, the second tunnel member having a        proximal end and a distal end, the second tunnel member having a        second longitudinal passage at least partway through the second        tunnel member; and    -   a passer operable to extend from the proximal end of the second        tunnel member, through the distal end of the second tunnel        member, through the distal end of the first tunnel member, and        to the proximal end of the first tunnel member in one continuous        path.-   2. The instrument of example 1 wherein the first and second guide    axes define a guide angle between them, the guide angle being    adjustable.-   3. The instrument of example 1 wherein the guide body includes a    first arc member and a second arc member, the first arc member and    the second arc member being joined in sliding relationship along an    arc shaped path of constant radius, the guide body being adjustable    between a first position in which the first guide axis and the    second guide axis define a first angle between them and a second    position in which the first guide axis and the second guide axis    define a second angle between them, the second angle being greater    than the first angle.-   4. The instrument of example 3 wherein the first guide axis is    defined by a passage in the first arc member and the second guide    axis is defined by a passage in the second arc member.-   5. The instrument of example 3 wherein the first angle and the    second angle are in the range of 20 to 110 degrees.-   6. The instrument of example 5 wherein the first angle and the    second angle are in the range of 60 to 90 degrees.-   7. The instrument of example 1 further comprising third and fourth    guide axes, the second, third, and fourth guide axes intersecting    the first guide axis at the same location on the first guide axis.-   8. The instrument of example 1 wherein the first tunnel member is    fixed to the guide body.-   9. The instrument of example 1 wherein the first tunnel member    comprises a drill guide.-   10. The instrument of example 1 wherein the first tunnel member    comprises a bone punch.-   11. The instrument of example 10 wherein the first tunnel member    includes a first side wall and a first side opening in the first    side wall nearer the distal end than the proximal end, the first    longitudinal passage extending from the proximal end of the first    tunnel member toward the distal end of the first tunnel member and    communicating with the first side opening.-   12. The instrument of example 11 wherein the second guide axis    passes through the first side opening.-   13. The instrument of example 11 wherein the first tunnel member    includes a relief opening through the side wall opposite the first    side opening and communicating with the first longitudinal passage    and first side opening.-   14. The instrument of example 11 wherein the first tunnel member    includes indicia on an outer surface and operable to align with a    bone surface to indicate a depth of penetration of the first tunnel    member into a bone corresponding to a predetermined tunnel depth.-   15. The instrument of example 1 wherein the second tunnel member is    separate from the guide body and the second tunnel member engages    the guide body in axial sliding relationship along the second guide    axis.-   16. The instrument of example 1 wherein the second tunnel member    comprises a drill guide.-   17. The instrument of example 1 wherein the second tunnel member    comprises a bone punch.-   18. The instrument of example 17 wherein the second tunnel member    includes a second side wall and a second side opening in the second    side wall nearer the distal end than the proximal end, the second    longitudinal passage extending from the proximal end of the second    tunnel member toward the distal end of the second tunnel member and    communicating with the second side opening.-   19. The instrument of example 18 wherein the first tunnel member    includes a first side wall and a first side opening in the first    side wall nearer the distal end than the proximal end, the first    longitudinal passage extending from the proximal end of the first    tunnel member toward the distal end of the first tunnel member and    communicating with the first side opening, the first tunnel member    and second tunnel member being engageable at their distal ends so    that the first side opening and second side opening are in    communication with one another.-   20. The instrument of example 19 wherein the distal end of the    second tunnel member is operable to insert into the first side    opening with the second side opening in communication with the first    side opening.-   21. The instrument of example 20 further comprising an angled    surface at the distal end of the second longitudinal passage, the    angled surface facing the second side opening, the angled surface    operable to deflect the passer through the second side opening.-   22. The instrument of example 1 wherein the passer comprises a first    end and a second end, the passer defining a loop at its second end.-   23. The instrument of example 1 wherein the passer is formed of a    super elastic material.-   24. The instrument of example 1 wherein the passer has a length    greater than the combined length of the first and second    longitudinal passages.-   25. The instrument of example 22 wherein the loop is bent.-   26. The instrument of example 22 wherein the passer comprises a    shaft and a wire extending from the shaft, the shaft extending away    from the first end, the shaft having a shaft length, the shaft being    relatively rigid compared to the wire, the wire being attached to an    end of the shaft and extending away from the shaft to the second end    where the wire defines the loop, the wire extending from the rigid    shaft a wire length, the wire being relatively flexible compared to    the shaft.-   27. The instrument of example 26 wherein the passer further    comprises an outer tube engaged with the shaft in axial sliding    relationship and moveable relative to the shaft from a first    position in which the outer tube encloses a portion of the wire    length and a second position in which the outer tube encloses less    of the wire length.-   28. An instrument for placing a member transosseously through first    and second transverse, intersecting bone tunnels in a bone, the    instrument comprising:    -   a guide body defining a first guide axis and a second guide        axis, the first guide axis and the second guide axis        intersecting at a location spaced from the guide body;    -   a first tunnel member engageable with the guide body coaxial        with the first guide axis, the first tunnel member having an        outer surface, a proximal end, a distal end, and a first        longitudinal passage at least partway through the first tunnel        member, the first tunnel member outer surface having a recess        formed therein and communicating with the first longitudinal        passage;    -   a second tunnel member engaged with the guide body coaxial with        the second guide axis, the second tunnel member having an outer        surface, a proximal end, a distal end, and a second longitudinal        passage at least partway through the second tunnel member, the        second tunnel member outer surface having an opening formed        therein and communicating with the second longitudinal passage,        the recess of the first tunnel member being operable to receive        the distal end of the second tunnel member with the opening        communicating with the recess, wherein the first longitudinal        passage, recess, opening, and second longitudinal passage form a        continuous passage from the proximal end of the first tunnel        member to the proximal end of the second tunnel member.-   29. The instrument of example 28 wherein the recess is transverse to    the first longitudinal axis and the opening is transverse to the    second longitudinal axis.-   30. The instrument of example 28 further comprising a passer having    an elongate flexible portion operable to simultaneously extend    through both the first and second longitudinal passages while the    second tunnel member is received in the recess of the first tunnel.-   31. The instrument of example 28 wherein the guide body includes a    first arc member and a second arc member, the first arc member and    the second arc member being joined in sliding relationship along an    arc shaped path of constant radius, the guide body being adjustable    between a first position in which the first guide axis and the    second guide axis define a first angle between them and a second    position in which the first guide axis and the second guide axis    define a second angle between them, the second angle being greater    than the first angle.-   32. The instrument of example 31 wherein the first guide axis is    defined by a passage in the first arc member and the second guide    axis is defined by a passage in the second arc member.-   33. The instrument of example 31 wherein the first angle and the    second angle are in the range of 20 to 110 degrees.-   34. The instrument of example 31 wherein the first angle and the    second angle are in the range of 60 to 90 degrees.-   35. The instrument of example 28 wherein the first tunnel member is    fixed to the guide body.-   36. The instrument of example 28 wherein the first tunnel member    comprises a drill guide.-   37. The instrument of example 28 wherein the first tunnel member    comprises a bone punch.-   38. The instrument of example 28 wherein the first tunnel member    includes a relief opening through the side wall opposite the recess    and communicating with the first longitudinal passage and recess.-   39. The instrument of example 28 wherein the first tunnel member    includes indicia on an outer surface and readable relative to a bone    surface to indicate a depth of penetration of the first tunnel    member into a bone corresponding to a predetermined tunnel depth.-   40. The instrument of example 28 wherein the second tunnel member is    separate from the guide body.-   41. The instrument of example 40 wherein the second tunnel member    engages the guide body in axial sliding relationship along the    second guide axis.-   42. The instrument of example 28 wherein the second tunnel member    comprises a drill guide.-   43. The instrument of example 28 wherein the second tunnel member    comprises a bone punch.-   44. The instrument of example 28 further comprising an angled    surface at the distal end of the second longitudinal passage, the    angled surface facing the opening, the angled surface operable to    deflect the passer through the opening.-   45. The instrument of example 28 wherein the passer comprises a    first end and a second end, the passer defining a loop at its second    end.-   46. The instrument of example 45 wherein the passer is formed of a    super elastic material.-   47. The instrument of example 28 wherein the passer has a length    greater than the combined length of the first and second    longitudinal passages.-   48. The instrument of example 45 wherein the loop is bent.-   49. The instrument of example 28 wherein the passer comprises a    relatively rigid shaft extending away from the first end, a    relatively flexible wire attached to the shaft and extending away    from the shaft to the second end.-   50. An instrument for placing a member transosseously through first    and second transverse, intersecting bone tunnels, the instrument    comprising:    -   a guide body defining a first guide axis, a second guide axis,        and a third guide axis, the second and third guide axes        intersecting the first guide axis at a location spaced from the        guide body, the second and third guide axes intersecting the        first guide axis at the same location;    -   a first tunnel member engaged with the guide body coaxial with        the first guide axis, the first tunnel member having a proximal        end and a distal end, the first tunnel member having a first        longitudinal passage at least partway through the first tunnel        member, the first tunnel member including a first side wall and        a first side opening in the first side wall nearer the distal        end than the proximal end, the first longitudinal passage        extending from the proximal end of the first tunnel member        toward the distal end of the first tunnel member and        communicating with the first side opening;    -   a second tunnel member engaged with the guide body coaxial with        the second guide axis, the second tunnel member having a        proximal end and a distal end, the second tunnel member having a        second longitudinal passage at least partway through the second        tunnel member, the second tunnel member including a second side        wall and a second side opening in the second side wall nearer        the distal end than the proximal end, the second longitudinal        passage extending from the proximal end of the second tunnel        member toward the distal end of the second tunnel member and        communicating with the second side opening, the first tunnel        member and second tunnel member being engageable at their distal        ends so that the first side opening and second side opening are        in communication with one another; and    -   a passer operable to extend from the proximal end of the second        tunnel member, through the second side opening, through the        first side opening, and to the proximal end of the first tunnel        member in one continuous path.-   51. The instrument of example 50 wherein the distal end of the    second tunnel member is operable to insert into the first side    opening with the second side opening in communication with the first    side opening.-   52. The instrument of example 50 further comprising an angled    surface at the distal end of the second longitudinal passage, the    angled surface facing the second side opening, the angled surface    operable to deflect the passer through the second side opening.

What is claimed is:
 1. An instrument for placing a member transosseouslythrough first and second transverse, intersecting bone tunnels, theinstrument comprising: a guide body defining a first guide axis and asecond guide axis, the first guide axis and the second guide axisintersecting at a location spaced from the guide body; a first tunnelmember engaged with the guide body coaxial with the first guide axis,the first tunnel member having a proximal end and a distal end, thefirst tunnel member having a first longitudinal passage at least partwaythrough the first tunnel member; a second tunnel member engaged with theguide body coaxial with the second guide axis, the second tunnel memberhaving a proximal end and a distal end, the second tunnel member havinga second longitudinal passage at least partway through the second tunnelmember; and a passer operable to extend from the proximal end of thesecond tunnel member, through the distal end of the second tunnelmember, through the distal end of the first tunnel member, and to theproximal end of the first tunnel member in one continuous path.
 2. Theinstrument of claim 1 wherein the first and second guide axes define aguide angle between them, the guide angle being adjustable.
 3. Theinstrument of claim 1 further comprising third and fourth guide axes,the second, third, and fourth guide axes intersecting the first guideaxis at the same location on the first guide axis.
 4. The instrument ofclaim 1 wherein the first tunnel member is fixed to the guide body. 5.The instrument of claim 1 wherein the first tunnel member comprises adrill guide.
 6. The instrument of claim 1 wherein the first tunnelmember comprises a bone punch.
 7. The instrument of claim 6 wherein thefirst tunnel member includes a first side wall and a first side openingin the first side wall nearer the distal end than the proximal end, thefirst longitudinal passage extending from the proximal end of the firsttunnel member toward the distal end of the first tunnel member andcommunicating with the first side opening.
 8. The instrument of claim 7wherein the second guide axis passes through the first side opening. 9.The instrument of claim 7 wherein the first tunnel member includes arelief opening through the side wall opposite the first side opening andcommunicating with the first longitudinal passage and first sideopening.
 10. The instrument of claim 7 wherein the first tunnel memberincludes indicia on an outer surface and operable to align with a bonesurface to indicate a depth of penetration of the first tunnel memberinto a bone corresponding to a predetermined tunnel depth.
 11. Theinstrument of claim 1 wherein the second tunnel member is separate fromthe guide body and the second tunnel member engages the guide body inaxial sliding relationship along the second guide axis.
 12. Theinstrument of claim 1 wherein the second tunnel member comprises a drillguide.
 13. The instrument of claim 1 wherein the second tunnel membercomprises a bone punch.
 14. The instrument of claim 13 wherein thesecond tunnel member includes a second side wall and a second sideopening in the second side wall nearer the distal end than the proximalend, the second longitudinal passage extending from the proximal end ofthe second tunnel member toward the distal end of the second tunnelmember and communicating with the second side opening.
 15. Theinstrument of claim 14 wherein the first tunnel member includes a firstside wall and a first side opening in the first side wall nearer thedistal end than the proximal end, the first longitudinal passageextending from the proximal end of the first tunnel member toward thedistal end of the first tunnel member and communicating with the firstside opening, the first tunnel member and second tunnel member beingengageable at their distal ends so that the first side opening andsecond side opening are in communication with one another.
 16. Theinstrument of claim 15 wherein the distal end of the second tunnelmember is operable to insert into the first side opening with the secondside opening in communication with the first side opening.
 17. Theinstrument of claim 16 further comprising an angled surface at thedistal end of the second longitudinal passage, the angled surface facingthe second side opening, the angled surface operable to deflect thepasser through the second side opening.
 18. The instrument of claim 1wherein the passer comprises a first end and a second end, the passerdefining a loop at its second end.
 19. The instrument of claim 1 whereinthe passer has a length greater than the combined length of the firstand second longitudinal passages.
 20. The instrument of claim 18 whereinthe loop is bent.
 21. The instrument of claim 18 wherein the passercomprises a shaft and a wire extending from the shaft, the shaftextending away from the first end, the shaft having a shaft length, theshaft being relatively rigid compared to the wire, the wire beingattached to an end of the shaft and extending away from the shaft to thesecond end where the wire defines the loop, the wire extending from therigid shaft a wire length, the wire being relatively flexible comparedto the shaft.
 22. The instrument of claim 21 wherein the passer furthercomprises an outer tube engaged with the shaft in axial slidingrelationship and moveable relative to the shaft from a first position inwhich the outer tube encloses a portion of the wire length and a secondposition in which the outer tube encloses less of the wire length. 23.An instrument for placing a member transosseously through first andsecond transverse, intersecting bone tunnels in a bone, the instrumentcomprising: a guide body defining a first guide axis and a second guideaxis, the first guide axis and the second guide axis intersecting at alocation spaced from the guide body; a first tunnel member engageablewith the guide body coaxial with the first guide axis, the first tunnelmember having an outer surface, a proximal end, a distal end, and afirst longitudinal passage at least partway through the first tunnelmember, the first tunnel member outer surface having a recess formedtherein and communicating with the first longitudinal passage; a secondtunnel member engaged with the guide body coaxial with the second guideaxis, the second tunnel member having an outer surface, a proximal end,a distal end, and a second longitudinal passage at least partway throughthe second tunnel member, the second tunnel member outer surface havingan opening formed therein and communicating with the second longitudinalpassage, the recess of the first tunnel member being operable to receivethe distal end of the second tunnel member with the openingcommunicating with the recess, wherein the first longitudinal passage,recess, opening, and second longitudinal passage form a continuouspassage from the proximal end of the first tunnel member to the proximalend of the second tunnel member.
 24. The instrument of claim 23 whereinthe recess is transverse to the first longitudinal axis and the openingis transverse to the second longitudinal axis.
 25. The instrument ofclaim 23 further comprising a passer having an elongate flexible portionoperable to simultaneously extend through both the first and secondlongitudinal passages while the second tunnel member is received in therecess of the first tunnel.
 26. An instrument for placing a membertransosseously through first and second transverse, intersecting bonetunnels, the instrument comprising: a guide body defining a first guideaxis, a second guide axis, and a third guide axis, the second and thirdguide axes intersecting the first guide axis at a location spaced fromthe guide body, the second and third guide axes intersecting the firstguide axis at the same location; a first tunnel member engaged with theguide body coaxial with the first guide axis, the first tunnel memberhaving a proximal end and a distal end, the first tunnel member having afirst longitudinal passage at least partway through the first tunnelmember, the first tunnel member including a first side wall and a firstside opening in the first side wall nearer the distal end than theproximal end, the first longitudinal passage extending from the proximalend of the first tunnel member toward the distal end of the first tunnelmember and communicating with the first side opening; a second tunnelmember selectively engageable with the guide body coaxial with one ofthe second and third guide axes, the second tunnel member having aproximal end and a distal end, the second tunnel member having a secondlongitudinal passage at least partway through the second tunnel member,the second tunnel member including a second side wall and a second sideopening in the second side wall nearer the distal end than the proximalend, the second longitudinal passage extending from the proximal end ofthe second tunnel member toward the distal end of the second tunnelmember and communicating with the second side opening, the first tunnelmember and second tunnel member being engageable at their distal ends sothat the first side opening and second side opening are in communicationwith one another; and a passer operable to extend from the proximal endof the second tunnel member, through the second side opening, throughthe first side opening, and to the proximal end of the first tunnelmember in one continuous path.
 27. The instrument of claim 26 whereinthe distal end of the second tunnel member is operable to insert intothe first side opening with the second side opening in communicationwith the first side opening.
 28. The instrument of claim 27 furthercomprising an angled surface at the distal end of the secondlongitudinal passage, the angled surface facing the second side opening,the angled surface operable to deflect the passer through the secondside opening.